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319 Cards in this Set
- Front
- Back
Nonspecific signs/symptoms of increased ICP
|
Headaches (on awakening, dependent on head position, progressive)
AM nausea/vomiting Papilledema (swollen optic disc) Seizures |
|
Diagnostic test for CNS neoplasm
|
MRI w/ and w/o gadolinium
Brain biopsy is only definitive way to dx |
|
Ways to control elevated ICP
|
Steroids
Mannitol Hyperventilation |
|
Differential dx of ring-enhancing brain lesion
|
Metastatic cancer
Brain abscess Glioblastoma multiforme Lymphoma Toxoplasmosis |
|
Brain tumor in a transplant recipient or AIDS patient
|
Primary lymphoma
|
|
Most common sites of brain metastasis
|
Lung
Breast Skin Kidney GI |
|
Pathognomonic for neurofibromatosis II
|
Bilateral schwannomas
(otherwise is unilateral) |
|
CSF reveals malignant cells, elevated protein and lymphocytes, decreased glucose
+ focal neurologic deficits |
Meningeal carcinomatosis (cancer metastasizes to meninges via blood)
Tx w/ intrathecal chemo |
|
Hearing loss, tinnitis, loss of balance, nystagmus, motor sensory deficits of face; imaging shows mass
|
Schwannoma (cerebellopontine angle)
|
|
ICP is determined by
|
Volume of brain
Volume of blood Volume of CSF |
|
Secondary insults to brain s/p trauma
|
Hypotension
Hypoxia Hypercapnia (causes vasodilation --> increased ICP) Increased ICP Intracranial mass effect (subdural or epidural hematoma) Anemia |
|
Normal ICP
|
5-15 mm H2O
ICP>20 is worrisome |
|
Effects of increased ICP
|
Decrease in cerebral perfusion pressure ---> hypoperfusion --> loss of autoregulation --> cerebral vasodilation --> vasogenic edema --> increased ICP
Systemic BP becomes sole determinant of cerebral blood flow Transtentorial herniation may result |
|
Bilateral fixed and dilated pupils suggest
|
Increased ICP
|
|
What is target MAP in the context of ICP
|
Mean arterial pressure > 80 mmHg
ICP <20 mm Hg This keeps cerebral perfusion pressure >50 mm Hg (normal) |
|
Sgns of basilar skull fracture
|
Raccoon eyes - periorbital ecchymoses
Battle's sign - postauricular ecchymoses Hemotympanum CSF rhinorrhea/otorrhea |
|
Cushing's triad
|
Hypertension, bradycardia, respiratory irregularity
|
|
Treatment of increased ICP
|
ABCs
Lower ICP: - Reverse Trendelenburg position if spine is cleared - intubation + hyperventilation (decreased paCO2 --> prevents cerebral vasodilation) - maintain PaCO2 at 30-35 - Mannitol - Narcotics for sedation - NM paralysis (vecuronium or pancuronium) - Lower body temperature |
|
Risk factors for subdural hematoma
|
Brain atrophy (EtOH, elderly)
Pts undergoing anticoagulation |
|
Signs of subdural hematoma
|
Headache
Decreased level of consciousness (mass effect) Cortical dysfx |
|
Mechanism of myasthenia gravis
|
Autoantibodies against nicotinic acetylcholine receptors of NM junction --> reduced postsynaptic response to acetylcholine
|
|
Proximal, asymmetric mm weakness with preservation of sensation and reflexes, worse with exercise
|
Myasthenia gravis
|
|
Dx test for myasthenia gravis
|
Acetylcholine receptor antibody test
EMG shows decremental response to repetitive stimulation of motor neurons Edrophonium (Tensilon) test - improvement w/ anticholinesterase meds |
|
Myasthenia gravis associated with?
|
Thymoma
|
|
Tx for myasthenia gravis
|
AChE inhibitors
Thymectomy Corticosteroids; azathioprine, cyclosporine Plasmapheresis (removes Ab to acetylcholine receptors) IV immunoglobulin therapy for acute exacerbation |
|
Myasthenic crisis
|
Diaphragm and intercostal fatigue --> respiratory failure
Low threshold for intubation |
|
Lambert-Eaton is associated with?
|
Small cell lung cancer
|
|
Lambert Eaton mechanism
|
Autoantibodies against presynaptic calcium channels
|
|
Proximal muscle weakness, hyporeflexia, symptoms improved with repeated use
|
Lambert Eaton
|
|
Inheritance of duchenne's MD
|
X linked recessive
Mutation of dystrophin gene --> mm cell structure |
|
Progressive, symmetric mm weakness starting in childhood with pelvic girdle affected
|
Duchenne's MD
|
|
Signs/symptoms of Duchenne's
|
Gower's manuever (hands to get up)
Enlarged calf muscles - pseudohypertrophy as fat replaces mm Wheelchair confinement, resp failure, death in 30s |
|
Causes of syringomyelia
|
Cranial base malformation (Arnold-Chiari)
Intramedullary tumors Traumatic necrosis of spinal cord |
|
Bilateral loss of pain and temp sensation in caplike distribution
Muscle atrophy of hands and thoracic scoliosis Preservation of touch |
Syringomyelia (collection of fluid in spinal cord --> central cavitation of cervical cord)
|
|
Tx for syringomyelia
|
Syringosubarachnoid shunt (surgical)
|
|
Diagnosis of Duchenne's MD
|
Serum creatine phosphokinase
DNA testing |
|
Contralateral loss of pain and temperature
Ipsilateral hemiparesis Ipsilateral loss of position/vibration |
Brown-Sequard (spinal cord hemisection)
|
|
Tracts affected in syringomyelia
|
Lateral spinothalamic tracts
|
|
Tracts affected in Brown-Sequard
|
Spinothalamic
Corticospinal Dorsal columns |
|
Lower extremity weakness or plegia
Back pain Sensory deficits below level of lesion Sphincter disturbance (urinary retention) |
Transverse myelitis (often after viral infection)
|
|
Causes of Horner's syndrome (ipsilateral ptosis, miosis, anhydrosis)
|
Idiopathic (most common)
Pancoast tumor (superior sulcus) Internal carotid dissection Brainstem stroke Cervical spine injury |
|
Asymmetric muscle weakness, absent DTR, atrophic/flaccid muscles, normal sensation
|
Poliomyelitis
|
|
Aphasia is more common when which hemisphere is involved?
|
Left
|
|
Visual spatial deficits are more common when what hemisphere is involved?
|
Right
|
|
Crossed hemiplegia (ipsilateral face and contralateral body) can be localized where?
|
Brainstem (corticospinal tract, dorsal columns, spinothalamic tract cross but CN do not)
|
|
Spinal cord injury - how to localize?
|
Level of lesion corresponds to sensory level (pinprick felt above level but not below)
|
|
Localize this lesion:
Weakness, atrophy, sensory deficits in dermatomal pattern, +/- fasciculations and diminished DTRs |
Roots (radiculopathy) or
Peripheral nerves |
|
Meniere's disease
|
Vertigo
Tinnitus Hearing loss |
|
Differences between central and peripheral vertigo:
|
Central: gradual onset, mild intensity, associated neurologic findings, mild nystagmus (multidirectional and vertical)
Peripheral: Sudden onset, severe intensity, rapidly refractory, unilateral vertical nystagmus |
|
Tilt-table testing used for
|
Dx neurocardiogenic syncope (if episodes are recurrent, unexplained, no structural heart disease)
|
|
Causes of epilepsy
|
4 Ms:
Metabolic (Hyponatremia, uremia) Mass lesions Missing drugs (withdrawal, noncompliance) Misc (pseudoseizures, eclampsia, hypertension) 4 I's: Intoxications Infections Ischemia Increased ICP |
|
Features of simple partial seizures
|
Consciousness intact
May involve transient unilateral clonic-tonic movements |
|
Features of complex partial seizures
|
Consciousness impaired
Postictal confusion Automatisms Olfactory/gustatory hallucinations |
|
Impaired consciousness, no loss of postural tone or continence, no postictal confusion
|
Absence seizures
|
|
Labs to order in unfamiliar seizing pt
|
Serum glu, Ca, sodium, BUN
|
|
Drugs of choice for generalized tonic-clonic and partial seizures
|
Phenytoin, carbamazepine
Phenobarbital, valproate, primidone |
|
Drugs of choice for petit mal (absence) seizures
|
Ethosuximide
Valproate |
|
ALS affects what areas?
|
UMN/LMN:
Anterior horn cells Corticospinal tracts Corticobulbar |
|
Progressive muscle weakness first noted in legs/arms, no associated pain, muscle atrophy
Exam findings: Muscle cramps and spasticity, fasciculations, impaired speech/swallowing, wt loss/fatigue, DOE/orthopnea |
ALS
|
|
Normal and unaffected even in late stages of ALS
|
Bowel/bladder control
Sensation Cognitive fx EOM |
|
Seen on EMG in myopathy
|
No electrical activity at rest, but amplitude decreases with mm conraction
|
|
EMG findings for MS, GBS
|
Decreased nerve conduction velocity
|
|
Riluzole MOA
|
Glutamate-blocking agent used to delay death in ALS (3-5 mo)
|
|
Receptive, fluent aphasia
Impaired comprehension of written or spoken language |
Wernicke's
|
|
Broca's aphasia
|
Expressive, nonfluent aphasia
Speech is slow, requires effort |
|
Where is lesion?
Aphasia + fluent speech |
Posterior to central sulcus
|
|
Where is lesion?
Aphasia + nonfluent speech |
Anterior to central sulcus
|
|
Brief, frequent attacks of severe lancinating facial pain
No motor or sensory paralysis |
THIS IS TRIGEMINAL NEURALGIA
Jaw, lips, gums, maxillary |
|
Drug of choice for trigeminal neuralgia
|
Carbamazepine
Baclofen Phenytoin Spont resolution in 85% cases |
|
Localize lesion:
Weakness is usually observed only in the lower face and tongue; extraocular, upper facial, pharyngeal, and jaw muscles are almost always spared |
Corticobulbar (unilateral)
|
|
Localize lesion:
dysarthria, dysphagia, dysphonia, and emotional lability accompany bilateral facial weakness and a brisk jaw jerk. |
Pseudobulbar palsy (bilateral corticobulbar tracts)
|
|
Localize lesion:
Homonymous visual field defect |
Cortical/subcortical
|
|
Difference in presentation, LMN vs. myopathy
|
LMN = distal weakness
Myopathy = proximal weakness |
|
Symmetric weakness of pelvic or shoulder girdle muscles
|
Myopathy
|
|
weakness of the lower two-thirds of the face with preservation of the upper third suggests?
|
UMN lesion
|
|
failure of vertical gaze
dysarthria dysphagia extrapyramidal rigidity gait ataxia dementia |
Progressive supranuclear palsy
|
|
In PSP what lobe abnls predominate
|
Frontal lobe
|
|
Pathology of PSP
|
Atrophy of dorsal midbrain, GP, STN
|
|
Argyrophilic round intraneuronal inclusions
|
Pick bodies (frontotemporal dementia)
|
|
Rapidly progressive dementia with pyramidal signs, myoclonus, cerebellar or extrapyramidal signs
Periodic sharp waves in EEG |
CJD
|
|
Presence of protein 14-3-3 in CSF
|
CJD
|
|
HIV associated dementia shows what on MRI
|
Cortical, subcortical atrophy
|
|
Neuropathy (paresthesias, sensory ataxia, visual loss, orthostatic hypotension), memory loss
Anemia, sore tongue |
Dementia due to Vit B12 deficiency
|
|
Lowering ICP
|
Raising head of bed
Hyperventilation Use of osmotic diuretic |
|
Red desaturation can be seen early in what problems?
|
Early optic nerve problems (e.g. optic neuritis)
|
|
Pupillary constrictor is innervated by?
|
Parasympathetic fibers of third nerve
|
|
Pupillary dilator is innervated by?
|
Cervical sympathetic system
|
|
Sympathetic system pathway
|
First order: Ipsilateral posterolateral hypothalamus to intermediolateral cell columns (C8-T1)
Second order: synapse in suprior cervical ganglion (pre-ganglionic) Third order: Travel along internal carotid artery into cavernous sinus --> pupillodilator muscle |
|
Compression of third nerve
|
Dilated pupil (Parasympathetic fibers on outside, motor fibers on inside)
|
|
Adie's pupil
|
Dilated (interruption of parasympathetic supply from ciliary ganglion)
segmental contraction, light-near dissociation |
|
Light-near dissociation
|
Pupillary constriction to light is greater than to near stimulus (NORMAL)
In LND: DEFECT in light response --> constriction to light < near response |
|
Adie's pupil (dilated, interrupted parasympathetic supply) can be demonstrated using?
|
0.1% pilocarpine --> contraction in affected pupil > normal pupil
|
|
"Dimming out" vision, precipitated by changes in posture, can occur many times/day
|
Optic disc swelling
Optic neurotis, ischemia |
|
Ilsilateral optic disc atrophy due to compression by space-occupying lesion in frontal lobe and papilledema in contralateral optic disc due to increased ICP
|
Foster-Kennedy syndrome
|
|
Painful visual loss; worse with exercise/hot baths; retro-orbital pain, loss of color discrimination, central scotoma, variable fundi
|
Optic neuritis (IV methyprednisolone)
|
|
Asymptomatic; enlarged blind spot with initially normal visual acuity; glistening hyaline bodies in fundi
|
Drusen or pseudopapilledema
|
|
Morning headache, ataxia, transient visual obscuration, central acuity spared, no color loss, enlarged blind spot, bilateral disc hyperemia
|
Increased intracranial pressure
|
|
Sudden painless visual loss in pt >50 yo, associated with HTN, DM
|
Ischemia
|
|
Incomitant gaze (degree of misalignment varies with direction of gaze) suggests what etiology?
|
Neurological (vs. ophthalmologic)
|
|
Oblique diplopia worse on downgaze when affected eye is adducted
|
CN IV lesion (SO intorts and depresses)
|
|
Destruction of abducens nucleus in brainstem
|
Complete ipsilateral conjugate gaze palsy (connection to contralateral third nerve through MLF)
|
|
Inability to adduct right eye in left lateral gaze + nystagmus of abducting left eye
|
R internuclear ophthalmoplegia (MLF lesion)
|
|
Upgaze disturbance, convergence-retraction nystagmus on attempted upgaze, light near dissociation of pupils
|
Parinaud's
Pineal tumor compressing dorsal midbrain |
|
Vestibulo-ocular reflex
|
Rotates eyes in the direction opposite to head movement
|
|
Voluntary saccades arise from?
|
Frontal eye field and superior colliculus contralateral to direction of gaze
|
|
Child between 2-7 yo following viral infection presents with acute onset limb, gait ataxia, dysarthria
|
Postinfectious cerebellitis
|
|
Acute/subacute onset of truncal, gait, limb ataxia; dysarthria; ocular dysmetria or nystagmus associated with cancer
|
Paraneoplastic cerebellar degeneration (gyn or small cell lung cancer --> nl MRI, assoc with autoantibodies)
|
|
Progressive ataxia in childhood with loss of reflexes, spasticity and extensor plantar responses, impaired vibration and position sense
|
Friedrich's ataxia (AR)
Arms more affected than legs |
|
Brief episodes of ataxia, vertigo, nausea, vomiting caused by mutations of?
|
Inherited episodic ataxia (EA-1): voltage gated K channel
EA-2: voltage gated calcium channel --> longer attacks w/ interictal nystagmus and progressive irreversible ataxia later in disease |
|
Insidious onset of progressive gait impairment, dysarthria in early adult life with mild-mod cognitive decline later on
|
Spinocerebellar ataxias (CAG expansion)
Autosomal dominant |
|
Triad of ATAXIA, AREFLEXIA, OPHTHALMOPLEGIA in postinfectious autoimmune process
|
Miller Fisher syndrome --> ataxia due to proprioceptive loss (not cerebellar dysfx)
|
|
Cerebellar vermal lesions assoc with?
|
Truncal and gait ataxia
|
|
Cerebellar hemispheric lesions assoc with?
|
Ipsilateral limb ataxia
|
|
Affected leg is stiff and does not flex at hip, knee, or ankle
Leg is circumducted (scrape floor with toes) Arm held in flexion and adduction, does not swing freely |
Hemiparetic gait
|
|
Spastic gait with increased adductor tone and legs tend to cross during walking
|
Scissoring gait (paraparetic/bilateral hemiparesis)
|
|
Electrical-like painful sensation (short paroxysms) in face
Triggered by tactile stimulus |
Trigeminal neuralgia
|
|
headache in a young obese woman, worse in AM, worse when recumbent, accompanied by pulsatile tinnitus and blurring precipitated by valsalva maneuver
|
Idiopathic intracranial HTN
(pseudotumor cerebri --> impaired resorption of CSF) |
|
Broca's aphasia: where is the lesion
|
Posterior part of inferior frontal gyrus in dominant (left) hemisphere
MCA territory |
|
Broca's aphasia - deficits?
|
Impaired fluency
Impaired repetition Normal comprehension |
|
Huntington disease triad
|
Chorea, behavioral change/personality disorder, dementia
|
|
Diagnosis of Huntington's
|
Family h/x
Clinical signs Caudate atrophy >40 CAG repeats |
|
Pathology in Huntington's disease
|
Destruction of caudate and putamen (striatal and nigral GABAergic neurons)
Loss of neurons in cerebral cortex |
|
Personality change, speech disturbance, inattentiveness, extrapyramidal signs, progressive dementia
|
Pick dementia
|
|
Rapidly progressive dementia with pyramidal signs, myoclonus, cerebellar or extrapyramidal signs, periodic sharp waves in EEG
|
CJD
|
|
CSF findings on CJD
|
Normal but presence of 14-3-3- protein (sensitive and specific)
|
|
Progressive dementia with neuropathy (paresthesias, sensory ataxia, visual loss, orthostatic hypotension), memory loss, anemia, sore tongue
|
Vit B12 deficiency
|
|
50% theta slow wave activity
|
Stage 1 sleep
|
|
Sleep spindles and K complexes
|
Stage 2 sleep
|
|
20-50% delta wave activity
|
Stage 3 sleep
|
|
>50% delta activity
|
Stage 4 (slow wave sleep)
|
|
A typical night of sleep
|
4-6 cycles, lasting 90 min each (stage 1 absent after first sleep cycle)
|
|
REM sleep with age
|
Decreases from 20-25% per night to 15-20% per night
|
|
REM sleep over course of night
|
REM accounts for greater proportion of sleep as night progresses
|
|
Drug that suppress stages 3 and 4 of sleep
|
Benzos
|
|
Drug that suppress REM sleep
|
Antidepressants and alcohol
|
|
Restless leg syndrome tx
|
Dopaminergic agents e.g. ropinirole, pramipexole
Anticonvulsants, opioids, benzos |
|
What can happen to restless leg syndrome symptoms with dopaminergic tx?
|
Augmentation: symptoms occur earlier in the day
|
|
Narcolepsy components:
|
Excessive daytime sleepiness with narcolepsy, cataplexy, sleep paralysis, hypnagogic hallucinations
|
|
Pathophysiology of narcolepsy/cataplexy
|
Loss of hypocretin secreting neurons in hypothalamus
|
|
Dx of narcolepsy
|
CSF with hypocretin <110
Multiple sleep latency test |
|
Cataplexy tx with?
|
TCAs clomipramine
Sodium oxabate SSRIs, atypical antidepressants |
|
Foster Kennedy Syndrome
|
Ipsilateral anosmia
Ipsilateral optic atrophy Contralateral papilledema |
|
Tx for chorea
|
Neuroleptics e.g. haloperidol (anti-dopaminergic)
|
|
Childhood onset of Parkinsonism with bradykinesia and rigidity, dystonia, myoclonus, seizures
|
Westphal variant, Huntington's diease
|
|
Dystonia
|
Sustained muscle contractions
|
|
Etiology for dystonia
|
Abnl low basal ganglia output structures
|
|
Cardinal features of Parkinson disease
|
Tremor at rest
Rigidity Hypokinesia Postural instability |
|
Sensory involvement in Parkinson disease
|
Loss of sense of smell
Pain Speech disturbance Autonomic disturbance Depression |
|
Early onset dementia
Delusions and hallucinations Fluctuations in consciousness Myoclonus |
Dementia with Lewy bodies
|
|
Supranuclear downgaze palsy and square wave jerks, upright posture, frequent falls
|
Progressive supranuclear palsy
|
|
Levodopa is broken down peripherally by?
|
Gut: aromatic amino acid decarboxylase (carbidopa inhibits)
Peripheral: COMT (entacapone, tolcapone inhibit) |
|
Dopaminergic agent requiring conversion
|
Levodopa
Dopamine agonists e.g. pramipexole, ropinirole, bromocriptine act directly |
|
Symptomatic tx in Parkinson's
|
Selegiline, rasagiline (MAO-B inhibitors)
Anticholinergics (trihexyphenidyl, diphenhydramine) Amantadine (NMDA receptor antagonist) |
|
Reduces cardinal features of parkinson's + drug-induced dyskinesias
|
Amantadine
|
|
Agents causing drug-induced Parkinsonism
|
Antipsychotics, antiemetics e.g. metoclopramide, prochlorperazine
|
|
Arching spasms of back, neck, stereotypical repetitive movements of tongue, jaw
|
Tardive dyskinesia
|
|
Risk factors for tardive dyskinesia
|
Advanced age
female gender Coexistent brain damage |
|
Tx for tardive dyskinesia
|
Increased doses of dopamine receptor blockers
Dopamine depletion (reserpine, tetrabenazine) |
|
Hemisection of spinal cord produces?
|
Ipsilateral hemiparesis
Ipsilateral loss of fine touch and vibration sensation Contralateral loss of pain and temperature below level of lesion |
|
Anterior cord syndrome
|
Bilateral spinothalamic tract (loss of pain and temp)
Bilateral weakness (corticospinal tract) Preservation of dorsal columns (fine touch, proprioception, vibration) |
|
Central cord syndrome
|
Bilateral loss of pain and temp sensation, weakness of upper extremities (motor fibers to legs are lateral and thus spared).
Preservation of fine touch |
|
Complete loss of motor and sensory function of upper and lower extremities + resp difficulty
Preserved reflexes mediated by CNs Loss of autonomic function |
High cervical spine cord injury
|
|
Air in acute EDH suggests?
|
Fracture of sinuses or mastoid air cells
|
|
Initial evaluation for suspected epidural hematoma
|
Noncontrast CT (homogenous density, high density, convex)
|
|
Characteristics of delirium
|
Cognitive impairment
Impaired attention Fluctuating course |
|
When is a head CT indicated for concussion?
|
LOC!!!!
Persistent headache Emesis Age >60 years Drugs/EtOH Persistent anterograde amnesia Soft tissue or bony injury above clavicles Seizure |
|
Post-concussion syndrome
|
Irritability
Depression Insomnia Subjective intellectual dysfx Anxiety Fatigue |
|
Return to Play - Grade 1 concussion
|
At least 15 min out, assessed at 5 min intervals
|
|
Return to Play - Grade 2 concussion
|
Removal from game -->return after 1 wk
|
|
Return to play - Grade 3 concussion (+LOC)
|
ER evaluation --> 1 week if exam nl
2 wks if LOC prolonged |
|
Atherosclerosis affects which brain vessels?
|
Carotid bifurcation
Major intracranial vessels Vertebral artery |
|
Lacunar strokes associated with?
|
(small vessels)
Occlusive disease of penetrating arteries in brain Assoc with HTN, DM |
|
Tx of ischemic stroke
|
tPA (within 3 hrs)
Antiplatelet drugs (aspirin, clopidogrel, dipyridamide) |
|
Complications of subarachnoid hemorrhage (delayed)
|
Vasospasm
Acute hydrocepalus |
|
Imaging type for detecting hyperacute ischemic injury caused by vasospasm
|
Diffusion-weighted MRI
|
|
Carotid dissection predisposing factors
|
Fibromuscular dysplasia
Ehlers-Danlos Marfan |
|
Carotid dissection often assoc with?
|
Ipsilateral ptosis + miosis (Horner's)
Headache Recent head/neck injury |
|
Drugs for absence seizures
|
Valproate, lamotrigine, ethosuximide, zonisamide
|
|
Automatisms - e.g. bilateral cycling, swimming movements - with post-ictal period, appear to be awake but do not respond normally to environment
|
Complex partial seizure
|
|
Seizure with preservation of consciousness (focal), + aura
|
Simple partial seizure
|
|
Momentary lapses in awareness without automatisms (can have blinking or lip smacking), no aura
|
Absence seizures
|
|
Aura involving abd sensation, fear, unreality, deja-vu
|
Temporal lobe seizure
|
|
Aura involving electrical sensation, tingling, numbness
|
Parietal lobe
|
|
Aura involving visual changes
|
Occipital lobe seizures
|
|
Characteristic pathologic changes for complex partial seizures
|
Mesial temporal sclerosis
|
|
SPECT findings for complex partial seizures
|
Hypoperfusion of bilateral frontal and parietal assoc cortex
Hyperperfusion of mediodorsal thalamus and rostral brainstem |
|
Acute LOC without nausea, sweating, abd discomfort, regained consciousness quickly without confusion
|
Cardiogenic syncope
|
|
Causes of syncope
|
Cardiogenic
Exertional (cardiac outflow obstruction) Vasovagal Epileptic seizure Orthostatic |
|
Nonepileptic syncope w/u includes
|
ECG, Echo, Holter monitor, orthostatics
|
|
Unilateral, periorbital/cheek pain
Onset in teens, 20s Precipitated by fatigue/stress, diet, sunlight, hormones Dull ache --> stabbing pain + Assoc symptoms |
Migraine
|
|
Precipitous headache in temporal region, unilateral, pain + stiffness in neck, shoulders, back, pelvic girdle
|
Temporal arteritis (assoc with polymyalgia rheumatica)
|
|
Post-spinal headache characteristics
|
Better when lying down, can be assoc w/ n/v
|
|
Sudden pulsatile head pain involving entire head, before or after orgasm
|
Postcoital cephalgia
|
|
Headache in young obese woman with menstrual irregularities, + visual disturbances
|
Benign intracranial hypertension
|
|
Sudden orbital or eye pain + n/v beginning after use of anticholinergic meds
|
Acute glaucoma
|
|
Orbital or neck pain + Horner syndrome after trauma
|
Carotid dissection
|
|
Headache assoc with brain tumor
|
Typical tension or migraine headache occurring frequently, may wake pt from sleep
+ Focal abnls |
|
Sudden onset headache with n/v/ stiff neck, fast decompensation, "worst headache"
|
Subarachnoid
|
|
Abortive therapy for migraine
|
Triptans
Ergotamine Dihydroergotamine Midrin: Isometheptene mucate (vasoconstrictor), dichloralphenazone (muscle relaxant), acetaminophen |
|
Triptan mechanism
|
5HT-1D receptor agonists
|
|
Side effects of triptans
|
N/V
Numbness/tingling CI if h/o CAD or HTN |
|
Prophylactic tx for migraines
|
Anticonvulsants (topiramate)
Beta-blockers (propanolol) Calcium channel blockers (verapamil) Antidepressants |
|
Chronic daily headache characteristics
|
Headache >15 days/month, >4 hrs/day
H/x of episodic migraines |
|
Tx for chronic daily heacahe
|
Removal of acetaminophen or aspirin (analgesic rebound worsens headaches)
Tramadol, propoxyphene (analgesic) - bridging Anticonvulsants, antidepressants, beta blockers and calcium channel blockers Botulinum toxin |
|
Botox is useful for what types of chronic daily headache?
|
Trigger points of head pain
Cervical pain or spasm |
|
Posterior cortical dementia
|
Intellectual functioning lost --> behavior preserved
e.g. Alzheimer's (early involvement of recent memory, language dysfx, apraxia, agnosia) |
|
The only "lower neurological fx" to be impaired in early Alzheimer disease
|
Olfaction
|
|
Imaging in AD shows?
|
Cortical atrophy (parietal, temporal, hippocampal)
|
|
Degeneration of cholinergic cells projecting from basal forebrain (nucleus basalis of Meynert) to cortex
Seen in? |
Alzheimer's
|
|
Insidious decline in cognitive function in pts with cerebrovascular disease (e.g. HTN) --> diffuse subcortical white matter changes on imaging
|
Binswanger disease (vs. STEPWISE decline in multi-infarct)
|
|
Medical causes of dementia
|
Wernicke encephalopathy (B1)
Vit B12 deficiency Hypothyroidism HIV Neurosyphilis Normal press hydrocephalus MS, Huntington, neoplastic |
|
Dementia
Executive dysfx Motor parkinsonism Fluctuating cognition Hallucinations Sensitivity to neuroleptics Sleep-related disorder |
Diffuse Lewy Body dementia
|
|
Paresthesias in hands and feet
Loss of vibratory sense + pathological lesions in dorsal columns and lateral corticospinal tracts |
Subacute combined degeneration (vit B12)
+ beefy tongue, premature whitening of hair, megaloblastic anemia |
|
Nerve conduction studies in Vit B12 deficiency
|
Demyelination and denervation
|
|
Acute, unilateral loss of visual acuity or visual field + ocular pain in a young adult
|
Optic neuritis
|
|
Optic neuritis is assoc with?
|
Multiple sclerosis
Sjogren Guillain Barre HIV infection |
|
Optic neuritis tx
|
IV corticosteroids (hasten recovery but have no effect on visual fx or recurrence)
|
|
Tx for optic neuritis dx in MS
|
Interferon beta 1a
|
|
Weakness + stiffness
Tingling/pins and needles, numbness, band around torso Limb tremor, ataxia, scanning speech (cerebellar) Optic neuritis and trigeminal neuralgia |
Multiple sclerosis
|
|
Charcot's triad
|
Intention tremor
Dysarthria Nystagmus |
|
Severe, lancinating maxillary or mandibular pain - brief
|
Trigeminal neuralgia (carbamazepine)
|
|
Bright lesions on T2-weighted imaging, in corpus callosum and periventricular regions + inferior to tentorium
|
MS
|
|
Imaging technique to detect MS
|
T2 weighted images
FLAIR (fluid attenuated inversion recovery) Decreased N-acetylaspartate measured by SPECT + CSF - IgG and oligoclonal bands |
|
Tx for MS
|
IV steroids (do not decrease future attacks)
Immunomodulation - Interferon b-1a - interferon b-1b - Glatiramer acetate (synthetic polypeptide of myelin basic protein) |
|
Tx for MS patient with secondary progressive or worsening relapsing-remitting disease
|
IV mitoxantrone (antineoplastic immunomodulatory agent)
|
|
Oligoclonal bands are found in?
|
SLE
Neurosarcoidosis SSPE Subarachnoid hemorrhage Syphilis CNS lymphoma |
|
Multiple neurologic symptoms 1-3 weeks post-infection or vaccination in young adult/children
|
Acute Disseminated Encephalomyelitis
|
|
Pathology of ADEM
|
Perivenular demyelination, relative sparing of axons
(peripheral subcortical cerebral white matter, thalami) |
|
Distinguish between MS and ADEM
|
Post-infection
Early-onset ataxia High lesion load on MRI Involvement of deep gray matter (thalami) Absence of oligoclonal bands |
|
Tx for ADEM
|
Corticosteroids can shorten duration of disease
|
|
Mechanism of botulinum toxin
|
Binds presynaptic cholinergic receptors on motor nerve terminals --> inhibit acetylcholine release --> disrupted neurotransmission between nerve and end plate on muscle
|
|
Cancers that metastasize to brain
|
Lung
Breast Kidney Skin Uterus |
|
Non-neoplastic malformations involving neurons and glia near hypothalamus, involving neuroendocrine fx (precocious puberty or acromegaly); pts may experience paroxysms of laughter
|
Hypothalamic hamartomas
(gelastic seizures = paroxysmal laughter) |
|
Pt with AIDS and tumor that can directly invade optic nerve
|
Primary lymphoma
|
|
Hepatic encephalopathy causes changes to what cells?
|
Increased astrocytes
|
|
HTN encephalopathy will show what CSF changes?
|
Mod increase in CSF protein (<100)
|
|
Neuro consequence of chronic renal failure
|
Peripheral neuropathy - symmetric, distal, mixed sensorimotor due to axonal degeneration
Improved with dialysis |
|
Tx for restless leg syndrome
|
Gabapentin
Clonazepam L-dopa Dopamine agonists Opiates |
|
Type of visual field cut seen in vit B12 deficiency
|
Centrocecal scotoma
|
|
Cancers that metastasize to brain
|
Lung
Breast Kidney Skin Uterus |
|
Non-neoplastic malformations involving neurons and glia near hypothalamus, involving neuroendocrine fx (precocious puberty or acromegaly); pts may experience paroxysms of laughter
|
Hypothalamic hamartomas
(gelastic seizures = paroxysmal laughter) |
|
Pt with AIDS and tumor that can directly invade optic nerve
|
Primary lymphoma
|
|
Hepatic encephalopathy causes changes to what cells?
|
Increased astrocytes
|
|
HTN encephalopathy will show what CSF changes?
|
Mod increase in CSF protein (<100)
|
|
Neuro consequence of chronic renal failure
|
Peripheral neuropathy - symmetric, distal, mixed sensorimotor due to axonal degeneration
Improved with dialysis |
|
Tx for restless leg syndrome
|
Gabapentin
Clonazepam L-dopa Dopamine agonists Opiates |
|
Type of visual field cut seen in vit B12 deficiency
|
Centrocecal scotoma
|
|
Anemia, dermatitis, memory deficits in diet limited to corn
|
Pellagra
(nicotinic acid or tryptophan) |
|
spinocerebellar degeneration, polyneuropathy, pigmentary retinopathy - deficiency in?
|
Vit E (early childhood)
|
|
obesity + hypersomnia + sleep apnea
|
Pickwickian syndrome (hypoxemia, pulm HTN)
|
|
EEG findings with hepatic encephalopathy
|
Triphasic waves
|
|
Normal background posterior-dominant rhythm on EEG
|
alpha 8-12 Hz
|
|
Gait d/o in NPH looks like?
|
Apraxic gait (like Parkinson gait)
|
|
NPH on CT/MRI
|
Enlarged temporal/frontal horns of lateral ventricles out of proportion to cortical atrophy; blunted frontal horns
|
|
Language disturbance in Alzheimer's
|
Decreased fluency
Dysnomia Transcortical sensory aphasia Repetition intact |
|
Type of dementia in Huntington's
|
Subcortical - impaired executive fx and concentration
no aphasia, apraxia, amnesia (classical cortical features) |
|
Headache, dementia, psychosis, decreased consciousness, myopathic weakness, delay in relaxation phase of reflexes (hung up reflex), cerebellar ataxia
|
Hypothyroidism
|
|
Seizures, myoclonus, ataxia, supranuclear gaze disturbance, hypothalamic dysfx, dementia, pendular convergence movements of eyes w/ masticatory mm movement (oculomasticatory myorhythmia)
|
Whipple disease (T. whippelii)
|
|
Areas affected by progressive multifocal leukoencephalopathy (JC virus)
|
Subcortical white matter - occipital, parietal --> visual complaints, alien hand syndrome
lesions do not enhance |
|
Which drugs enhance chorea in Huntington's disease?
|
Dopaminergic (L-dopa, bromocriptine, lisuride)
|
|
Trihexylphenidyl MOA
|
decreases acetylcholine transmission --> can be used to counteract parkisonian side effects for neuroleptic drugs
|
|
Blepharospasm, forceful jaw opening, lip retraction, neck contractions, tongue thrusting, idiopathic in 6th decade
|
Meige syndrome
Tx: botulinum |
|
Tx for tremor that comes on with action, involves arms/head, diminished with EtOH
|
Beta-blockers
Primidone (anticonvulsant) |
|
Side effect of metoclopramide hydrochloride (Reglan)
|
parkisonism, tardive dyskinesia
|
|
Lhermitte sign
|
Electrical sensation radiating down spine when neck is passively flexed (spinal cord disease, MS)
|
|
Tx to reduce freq of MS flares
|
Interferon beta-IB
Glatiramer (immunomodulator) Glucocorticoids to tx acute flare |
|
Developmental regression at 6 month, extensor posturing + rigidity, myoclonic seizures (defect in NAA metabolism --> elevated levels in brain), brain has spongiform appearance
|
Canavan disease
|
|
Symptomatic tx for MS
|
Baclofen (antispasmodic)
Tizanidine (a2-agonist, muscle relaxant) Benzodiazepine |
|
Bilateral optic neuritis + transverse myelitis (paraparesis, bladder/bowel dysfx, sensory deficit)
|
Neuromyelitis optica (more likely to develop relapsing-remitting MS)
|
|
Male children in first few months of life, + nystagmus, limb tremors, optic atrophy, chorea, seizures, gait ataxia
Demyelination with sudanophilic staining |
Sudanophilic leukodystrophy (Pelizaeus-Merzbacher disease)
|
|
Intracranial calcifications that follow gyral pattern of cerebral crotex --> railroad tracks on XR
|
Sturge-Weber
|
|
Lateral ventricles with typical batwing conformation
|
Agenesis of corpus callosum
|
|
Children with scaly erythematous rash on face, episodic ataxia
Hartnup disease - deficiency in? |
tryptophan (precursor for nicotinamide) and other neutral amnio acids
|
|
Polycystic liver disease
Polycystic kidney disease Retinal angiomas (telangiectasia) Cerebellar tumors Hemangiomas, adenomas, hemangioblastomas |
von Hippel-Lindau
|
|
Erythrocytosis with cerebellar signs
Microscopic hematuria Hepatosplenomegaly |
Von Hippel Lindau
|
|
Acanthocytes
Posterior column and spinocerebellar degeneration Retinitis pigmentosa |
Abetalipoproteinemia
|
|
Associated with Arnold-Chiari type 2 (downward displacement of cerebellar tonsils into foramen magnum)
|
Spina bifida
|
|
Retinal problem assoc with tuberous sclerosis
|
Retinal phakoma (gliomatous tumors)
CNS calcifications, ash-leaf spots, renal tumors, cardiac rhabdomyomas, seizure disorders |
|
enlargement of the fourth ventricle; a partial or complete absence of the cerebellar vermis, the posterior midline area of cerebellar cortex responsible for coordination of the axial musculature; and cyst formation near the internal base of the skull.
|
Dandy-Walker malformation
|
|
Effect of EtOH on developing brain
|
impaired neuronal migration --> MR, learning disabilities, hyperactivity, microcephaly
|
|
proximal muscle weakness in cancer patient
|
Dermatomyositis (paraneoplastic) - but not assoc with CNS tumors
|
|
man with problem relaxing grip, hypersomnolence, premature baldness, testicular atrophy, cataracts
|
Myotonic dystrophy
|
|
EMG pattern for myotonic dystrophy
|
"Dive bomber pattern"
(repetitive discharges with minor conduction defect) |
|
Signs of poor prognosis in ALS
|
Facial fasciculations
Diaphragmatic weakness |
|
Most common site of CNS atrophy associated with chronic alcoholism
|
Superior vermis
|
|
organophosphate toxicity
|
Severe motor polyneuropathy (UMN and LMN)
anticholinesterase activity = headache, vomiting, abd cramps, sweating, wheezing |
|
Toxic lead exposure
|
Brain edema --> herniation
Low levels = ataxia, tremor, bilateral NEUROPATHIES |
|
Pyridostigmine, physostigmine, edrophonium are?
|
Anticholinesterase
|
|
Atropine is a?
|
Anticholinergic
|
|
Toxicity:
Personality change, tremor, ataxia in a paper/pulp/electrochemical plant |
Mercury
Damage to cerebellum, calcarine cortex of occipital lobe (visual field constriction) |
|
Toxicity: wrist and finger drops and mild sensory abnormalities in distribution of radial nerves
|
Lead toxicity
+ abd pian, constipation, anemia, basophilic stippling, lead lines along gingival margin |
|
Toxicity: Mucosal irritation, hemolysis, tonic-clonic seizures, polyneuropathy, psych changes
|
Arsenic
|
|
Toxicity: peripheral neuropathy, degeneration of posterior columns/dorsal roots assoc with rye ingestion
|
Ergot
|
|
Toxicity: Parkinsonism
|
MPTP
Manganese inhalation by miners |
|
Toxicity: Confusion, headache, coma/posturing/seizures --> delayed neurologic deterioration with parkinsonian features 1-3 weeks after initial event
|
CO
Hypodensities in globus pallidum |
|
Contralateral hemiparesis, retardation, seizures, glaucoma, intracranial calcifications assoc with leptomeningeal angiomatosis
|
Sturge-Weber (port wine stain)
|
|
Effects of HTN on retina
|
Segmental narrowing of arterioles
Nicking (arteriolar-venular compression) Arteriolar straightening |
|
Retinal microaneurysms are associated with?
|
DM
|
|
Osteomyelitis of the petrous pyramid leading to abducens and trigeminal nerve injury
|
Gradenigo syndrome (facial pain and diplopia)
|
|
Trauma to the face is most likely to injure which mm of the eye?
|
Superior oblique (CN 4) --> impaired intorsion of eye --> slight head tilt
|
|
Eye nerve most likely affected by varicella zoster
|
CN 4
Shares nerve sheath with V1 (herpes zoster spreads to face along trigeminal nerve) |
|
MLF syndrome
|
weak adduction of affected eye
abduction nystagmus of contralateral eye |
|
Jerky downward motion of both eyes with slow return
|
Ocular bobbing - pontine damage
slower than downbeat nystagmus + brief tonic interval before slow return |
|
Transient loss of vision caused by disease of arteries - which artery?
|
Internal carotid (emboli)
|
|
Bilateral dilated pupils in otherwise healthy woman +/- absent tendon reflexes
|
Adie tonic pupil (most often benign; degeneration of ciliary ganglion)
|
|
Absence of thiamine in EtOHic leads to?
|
Periaqueductal and mamillary body lesions --> autonomic failure
|
|
Decremental response of muscles to repetitive stimulation of nerve at low frequency
Incremental response to repetitive stimulation at high frequency |
Botulism
|
|
Bugs most responsible for meningitis in 6 mo old
|
H. flu
Strep neumo N. meningitidis <3 mo old Group B strep E. coli Listeria |
|
Signs of cauda equina compression
|
Loss of bowel and bladder control
Paraparesis/paraplegia |
|
Deteriorating consciousness, autonomic disturbances (hypotension, hypothermia), ocular motor problems, gait difficulty in an alcoholic
|
Wernicke encephalopathy --> hemorrhagic necrosis
|
|
Acute severe fever, tachypnea, tachycardia, rigidity --> diffuse segmental muscle necrosis
|
Malignant hyperthermia
|
|
Fourth nerve palsy (superior rectus)
|
Difficulty looking down and medially (can't go down stairs)
|
|
Evidence of basilar skull fracture
|
Periorbital ecchymosis (raccoon eyes)
Ecchymosis over mastoid region (Battle sign) Hemotympanum CSF rhinorrhea/otorrhea |
|
Person with head trauma has multiple punctate hemorrhage on MRI - reason?
|
Diffuse axonal injury - swelling in white matter, corpus callosum, upper brainstem.
|
|
Tx for trigeminal neuralgia
|
Carbamazepine
Phenytoin Baclofen |
|
Tx for incontinence in MS
|
Imipramine
Oxybutynin (anticholinergic) |
|
Tx for spasticity
|
Baclofen
Tizanidine |
|
Tx for status epilepticus
|
Lorazepam/Diazepam IV
+ phenytoin in conjunction to prevent relapse (IV) |
|
Tx of glioblastoma multiforme
|
Complete gross resection + radiation therapy
|